Presented by
 Dr. Amit kumar Shah
( Intern Doctor)
Department of Surgery
TMC & RCH

Particulars of the patient
Name:Ms.SafuraBegam
Age:38years
Sex:Female
Address:Kalupuri,kahaloo,bogura
Maritalstatus: Married
 Religion :Islam
Dateofadmission:14/11/22@5.5pm
Dateofexamination:17/11/22@10.30am

Chief complaints
Recurrentpainintheupperabdomenfor3years

History of present illness
Accordingtothestatement ofpatientShewas
reasonablywell 3yearsbacktheshedeveloped
recurrentpainintheepigastrium whichwas
constantdullachinginnature,radiatingtoback,
aggravatedbytakingfattyfoodand releived by
bendingforwardandmedication. Thepainhadno
periodicity. Thepainwassometime associatedwith
nauseaandvomittingandcontainedundigested
foodparticles.

Forlast1yearwithanepisodes ofabdominalpain,
noticedpassageofgreasystools,2-3episodes/day,
normalvolume, nonfoulsmelling, associated with
oildroplet,difficulttoflushwhichisnotassociated
withabdominalbloatingsensationandflatulence.
Insomeoccasionthepainbecomesudden,severe
andagonizinginnatureanddidn’trelieved by
takinganalgesic

Forthatreasonshewasadmittedtohospital3times
andwastreatedconservatively. Shegavenohistory
offever, jaundice,heartburn,chestpain,respiratory
distress,nohistoryofNSAIDbeforetheonsetof
pain,haematemesis ormelenaorpassageofloose
stool.Sheisnormotensive anddiabetic.Herbowel
andbladderhabitisnormal.

History of past illness
HistoryofDMforlast7years,Nonhypertensive

Treatment History
Shewasadmitted inlocalupazilla hospital3times
andwastreatedconservatively.

Family History
Sheis3rd issueofanon-consanguinusmarriage
andevery familymember arehealthyandaliveand
havenosimilar healthissues

Personal history
She is non-alcoholic, non smoker but
betel nut chewer . She is accustomed
to normal bengali diet.

Allergic history
Sheisnotallergic any knowdrugs

Menstrual history
MC: regular28+/-2
MF:normal
MP:5to7days
Obstetric History
1alivechildof18yearsmale

General Examination
Appearance:illlooking
Bodybuilt:below average
Cooperation:cooperative
Decubitus :onchoice
Nutritionalstatus:below average
Anemia:absent
Jaundice:absent

Cyanosis:absent
Clubbing:absent
Dehydration:moderatelydehydrated
Edema:absent
Koilonychia:absent
Leuconychia:absent

Pulse: 122/min
Bp:120/70mmhg
Temp:N
RR:16/min
Lymphnode:notenlagred
Herniaorifice:intact

Alimentary examination
Oralcavity,gum,teeth –appearednormal
Oninspection:
Abdomenwasnormalinshape,umblicus centrally
placedinverted. Allquadrantmovesequallywith
respirationandisthoraco-Abdominal.Novisible
lumpinanyofthequadrantnorwasanyswelling at
hernialsite.

Onsuperficial palpation:localtemperaturewas
normal,tenderness waspresent inepigastrium,
muscle guardandmusclerigiditywerepresentin
epigastric region.
Ondeeppalpation:
Liver, spleen isnotpalpable.Bothkidneyarenot
palpableorballotable. Fluidthrillwasabsent.
Murphy’ssign:negative

Onpercussion:
Percussionnotewastympanic alloverthe
abdomen.Shiftingdullness wasabsent.
Onauscultation:
bowelsoundwaspresentandnoanyaddedsound.

Cardiovascularexaminationrevels pulse122/min,
whichisnormalinrhythm,allperipherypulseare
palpable.
Respiratory,nervoussystemandothersystem
examinationrevels noabnormalities.

Silent features
Misssofurabegum38yearsolddiabetic, non
hypertensive ladyhailingfrom kahalooBoguraand
gotadmitted toTMCandRCHwithacomplaintof
recurrentpainintheepigastrium for3years.then
shedeveloped recurrentpainintheepigastrium
whichwasconstantdullachinginnature,radiating
toback,

aggravatedbytakingfattyfoodand releived by
bendingforwardandmedication. Thepainhadno
periodicity. Thepainwassometime associatedwith
nauseaandvomittingandcontainedundigested
foodparticles. Forlast1yearwithanepisodes of
abdominalpain,noticedpassageofgreasystools,
2-3episodes/day,normalvolume,nonfoulsmelling,
associatedwithoildroplet,

difficulttoflushwhichisnotassociated with
abdominalbloatingsensationandflatulence. In
someoccasionthepainbecomesudden,severeand
agonizinginnatureanddidn’trelieved bytaking
analgesic. Forthatreasonshewasadmittedto
hospital3times andwastreatedconservatively.

Shegavenohistoryoffever,jaundice,heartburn,
chestpain,respiratorydistress,nohistoryofNSAID
beforetheonsetofpain,haematemesis ormelena
orpassageofloosestool.Sheis normotensiveand
diabetic.Herbowelandbladderhabitisnormal.

Onexaminationsheisill-looking moderately
dehydrated,anoxious,tachycardiac(pulse122/min)
withoutpallororjaundice,tenderness waspresent
inepigastrium, muscle guardandmuscle rigidity
werepresentinepigastric region.Soitislikely due
tochronicpancreatitis.

Chronicpancreatitis

Differential Diagnosis
PepticulcerDisease
Chroniccholecystitis

Investigation
Testtoestablishthediagnosis
 Ultrasound
 CT(mayshowatrophy, calcification,orductaldilatation)
 MRCP
 EndoscopicUltrasound
Testforpancreaticfunction:1)collectionofpurepancreaticjuiceafter
secretininjection(itisgoldstanderbutinvasiveandseldomused
2)Faecalpancreaticelastase
Testofanatomypriortosurgery: MRCP

INVESTIGATION
Investigations Findings
1. CBC HB:12.1gm/dL
WBC count: 11,300/ccmm
ESR: 50mm in 1st hour
PC: 321000/ccmm
2. Urine R/E Pus cell: 5-7/HPF
Epithelial cell: plenty
3. Serum creatinine 0.9mg/dL
4.RBS 216mg/dL

Investigation for
diagnosis:
 Ultrasonography of
whole abdomen:
showingdilatedmajor
pancreaticductwithmultiple
calculiandfeaturesof
chronicpancreatitis

MRCP :
Showing
chronic
calcificat
ion with
acute
exacerab
ation.

Confirm Diagnosis
Chronicpancreatitisduetopancreaticduct calculi

Treatment
1. Conservative management wasgiven afterthe
clinical diagnosisofpatient.
2. Interventioninchronicpancreatitis:
ENDOSCOPICTHERAPY
Dilatationorstenting ofpancreaticductstrictures
Removalofcalculi(mechanical orlithotripsy)
Drainageofpseudocysts

SURGICALMETHOD:
Partialpancreaticresection, preserving the
duodenum
Pancreaticojejunostomy

Thank You